Better Knowledge of Sex-Specific Differences in CV Risk Factors and Symptoms Could Save Lives, Improve Care

INNSBRUCK, Austria—“Cardiovascular disease is not a man’s disease,” and while it may seem like trends are headed in the right direction for women, more work still could be done, according to Imo Hoefer, MD, PhD (University Medical Center Utrecht, the Netherlands), who chaired a session on sex differences at the 2016 European Atherosclerosis Society Congress.

“Practice has already changed in many countries,” he told TCTMD in an email. “Awareness of cardiovascular disease in women has very much increased, and symptoms in women are certainly less likely to be overlooked.”

But in her presentation during the session, Eva Bossano Prescott, MD (University of Copenhagen, Denmark), said it has become clear that while more women than men die from heart disease, they typically do so at an older age—9 years later on average—and this creates a challenge for clinicians.

Additionally, women are more likely than men to have symptoms without having a stenosis, leading many physicians to not even think of treatment, she said. Women presenting with this pattern, often called syndrome X, tend to have higher levels of both depression and anxiety than women actually found to have a stenosis, Bossano Prescott continued. Because many women with syndrome X are not treated, their symptoms can continue for long periods of time and their quality of life suffers.

So counterintuitively, for some patients “coming out of the cath lab without a stenosis” is more bad news than good, at least with regard to symptoms, Bossano Prescott surmised.

Looking back, “COURAGE taught us that it’s not the lesion but the optimal medical therapy that is important for prognosis,” she said. “Initially we thought [treating the stenosis] would lead to better symptom control, . . . but symptoms are more or less the same.”

The future of symptom control for both women and men, but for women especially, lies in being able to diagnose microvascular disease, Bossano Prescott said, although “we are really in need of new methods” to do so. She likened microvascular disease to being the “rest of the iceberg,” and alluded to the potential role of biomarkers to help drive research forward.

“Cardiologists and patients usually think of coronary obstructions as the cause of myocardial ischemia and thus symptoms,” Hoefer added. “However, the percentage, particularly in women, of microvascular disease even seems to be higher than that of epicardial obstructions. This has to be kept in mind when treating patients for angina complaints.”

Addressing Risk Factors and Myths

In another presentation, Børge Nordestgaard, MD (University of Copenhagen) focused on the role of sex-specific risk factors in cardiovascular disease. Namely, while hypertension and smoking are generally bigger issues for men than women, women have more problems with obesity, he said, adding that the proportion of statin prescriptions is suboptimal in women.

Bringing these risk factors under control could prevent millions of untimely deaths not only from cardiovascular disease, but also from diabetes, cancer, and chronic obstructive pulmonary disease, he estimated.

And in yet another presentation, Kornelia Kotseva (Imperial College London, England), confronted several well-known myths about men and women in heart disease. Echoing what Hoefer said, she stressed that women need to be especially vigilant about their heart health and that physicians should fight to make sure their female patients are aware of symptoms, even if they are considered “fit.”

The latest European prevention guidelines, published last week, for the first time highlight specific targets for women, Kotseva noted. These should be included in risk assessments in the same way as for men, she said, reminding physicians to be aware of the 10-year “gap” in risk between women and men.

That said, “medical practice does not sufficiently take gender into account in diagnosis, treatment, or disease management,” she concluded. “This is further compounded by the fact that there are almost no systematic analyses of treatment differences between women and men.”